Falls are a leading preventable cause of death, injury, and reduced function and independence in adults aged 65 years and older. In 2020, the estimated US healthcare expenditure for nonfatal falls was $80.0 billion, with the majority paid by Medicare [1]. In 2011 [2], the American Geriatrics Society and British Geriatrics Society (AGS/BGS) updated their 2001 Clinical Practice Guideline for Prevention of Falls in Older Persons and Recommendations [3]. Using the 2011 AGS/BGS guidelines and incorporating input from national fall prevention experts, the Centers for Disease Control and Prevention (CDC) released the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) toolkit in 2012. STEADI program materials have been promoted widely across the United States and include the STEADI algorithm, fall risk assessment tools, clinician training resources, recommendations for clinic implementation, and public education materials [4].

The STEADI approach to fall prevention employs a screen, assess, and intervene framework to prevent falls in community-dwelling older adults. Screening tools include the Stay Independent questionnaire [5], a validated 12-item self-report instrument, yielding scores ranging from 0 (lowest risk) to 14 (highest risk), with a score > 3 indicating increased risk of falling. This tool has been adopted by multiple health systems as a fall risk screening instrument and is also known as the “Stay Independent Brochure” or “the STEADI questionnaire.” The “Three Key Questions” is three items of the 12-item instrument [6, 7], which is validated and endorsed by the CDC as a stand-alone instrument. These questions each have yes/no responses and are: Have you fallen in the past year?; Are you worried about falling?; and Do you feel unsteady when standing or walking?

In 2022, the World Falls Guidelines (WFG) Task Force published global recommendations for fall risk stratification, assessment, and interventions [8]. AGS convened a group of fall prevention experts to briefly summarize the new WFG, compare them to the AGS/BGS 2011 guideline, and offer suggestions for implementation in the United States. This publication was called the AGS Response to the WFG [9]. In 2024, the National Network of Public Health Institutes (NNPHI), via a Cooperative Award with the CDC of the Department of Health and Human Services (HHS), invited AGS to recommend updates and changes to the STEADI toolkit with a focus on falls prevention in primary care. The AGS convened a workgroup to develop these updates and changes. This special article in JAGS shares the recommendations that the AGS workgroup made to CDC that focus on enhancing the uptake of STEADI by primary care practices, Geriatrics Workforce Enhancement Programs, and others who are integrating fall prevention education and workflows or attention to safe mobility into clinical practice.

AGS convened a group of nine interprofessional clinicians and researchers with extensive experience in fall prevention to develop practical recommendations for CDC consideration as part of a planned future update to the STEADI suite of fall prevention materials. The AGS workgroup was assembled in January 2024, met virtually in Spring 2024, and convened in-person in June 2024.

The group undertook the following six major activities:

The AGS workgroup deemed many components of STEADI to be important and relevant in the care of older adults. The suggestions offered to CDC and in this paper are focused on how to increase the uptake of STEADI in primary care settings. The AGS workgroup has generated multiple resources for CDC to consider, including editing, modifying, and adding public education and clinician resources. Further, because being identified as having an increased risk of falls can be a sensitive topic for some older adults, the workgroup suggested reframing discussions of fall risk to focus on “improving balance,” “safe mobility,” or “staying independent” as these may be more accepted and relevant. In this context, increased fall risk can be presented as a chronic condition that merits ongoing management so all older adults can remain as independent as possible and maintain quality of life as they age, rather than just as an annual screening [3, 9]. Assessments and interventions can be organized similarly to those for other chronic conditions (e.g., diabetes) [14] with comprehensive team involvement, and regular, longitudinal follow-up. This approach aligns with the Centers for Medicare and Medicaid Services (CMS) Calendar Year 2025 (CY 2025) Medicare Physician Fee Schedule which finalized three codes for payment for advanced primary care management (APCM) services [30]. The new Healthcare Common Procedure Coding System (HCPCS) G-codes (G0556, G0557, G0558) to recognize APCM services stratified by the number of chronic conditions and whether the patient is a Qualified Medicare Beneficiary (QMB). The codes bundle certain management and communication technology-based services (CTBS) provided under an advanced primary care delivery model, which is defined as one where the practitioner is the continuing focal point for all needed health care services and responsible for all primary care services. CMS expects the new codes will simplify billing compared to existing care management and CTBS codes. This new coding recognizes elements that we believe are vital components of primary care, including team-based care and an ongoing, longitudinal relationship with the patient.

One consistent theme in feedback from PCPs with regard to fall prevention was lack of time. Respondents offered that integration of fall prevention into their clinical workflow was complex. Perhaps not surprisingly, several who had adopted STEADI eliminated specific components that were time-consuming or difficult to perform in their clinical setting. In response, the AGS workgroup recommended how to start with the time available and fit the highest priority element into that time. They noted that STEADI elements could then be spread across multiple visits, like other chronic conditions. Also, certain positive screening questions (endorsing feeling “unsteady while walking”) may point to the right intervention (refer to PT) allowing for the PCP office assessment to be skipped. The workgroup's recommendations offer an approach that can help busy primary care teams prioritize fall risk interventions based on time afforded, team member availability, and patient preferences. Creating efficiencies elsewhere would also allow for the inclusion of additional WFG evidence-based elements (e.g., hearing and cognitive screening). The AGS workgroup acknowledged that careful attention to fall prevention may lead to the identification of additional, previously unrecognized age-associated conditions and thereby could potentially increase the workload for already busy primary care teams. This possibility is mitigated by the new APCM services (as described above) which are designed to support provision of longitudinal, team-based care to Medicare beneficiaries. Clearly stating that this may happen and encouraging clinicians to treat fall prevention as a team effort focused on each patient's needs and health conditions over time can help prioritize the clinical work that follows fall screening and management, as shown in Figure 2 [12]. Longitudinal fall risk management can enhance attention to the Geriatrics 5Ms (what Matters, Mobility, Medication, Mentation, and Multicomplexity, see Figure 3) and aligns with the 4Ms approach to caring for older adults that is at the heart of the Age-Friendly Health Systems Movement [31], and assist primary care practices in identifying older patients most likely to benefit from multifactorial interventions for safer mobility.

Of course, clinical care takes place in a broader context: work in fall prevention touches upon multiple health policy and US health payment issues. From a policy perspective, the AGS workgroup advocates for Medicare coverage for all components of an updated STEADI (e.g., hearing amplification devices, adaptive equipment, reimbursement for PT/OT/community health workers, and other health care team members who offer fall-related interventions). Additionally, the US Preventive Services Task Force (USPSTF) Update on Fall Prevention offered a B recommendation for “exercise interventions”; specifically mentioned were “effective” interventions such as “supervised individual PT and group exercise classes” [32]. This noteworthy inclusion should have broad implications. According to the USPSTF, Section 2713 of the Affordable Care Act (ACA) requires private insurers to cover USPSTF-recommended services that have a Grade of A or B with no cost-sharing (i.e., no deductible and no co-pay) [33]. As well, Section 4106 of the ACA requires Medicaid to cover preventive services recommended by the USPSTF with a Grade of A or B [34]. The USPSTF gives a C recommendation that clinicians individualize the decision to offer multifactorial interventions to prevent falls to community-dwelling adults 65 years or older who are at increased risk for falls because the “net approach to routinely offering multifactorial interventions to prevent falls is small” [32]. Section 4105 of the ACA gives CMS the authorization to expand its coverage of preventive services consistent with USPSTF recommendations of Grade C [35]. Ensuring that the ACA mandates are met and encouraging CMS to exercise its authority to expand coverage to preventive services with USPSTF Grade C recommendation would broaden coverage for community-based exercise classes and other vital components of the STEADI initiative.

In summary, primary care teams are tasked with providing comprehensive, person-centered care to all of us as we age. Helping older adults to optimize fall prevention/safe mobility can be a major step toward meeting their goals for independence, autonomy, and aging in place. Doing so is aligned with the recent launch of a National Institutes of Health Program on Integrating Clinical Research into Primary Care Settings as well as with the Agency for Healthcare Research and Quality's ongoing investment in primary care research.

Given these changes in payment, the timing is right to recognize that falls are a chronic condition that warrants full attention in primary care. The workgroup discussed the current branding of the STEADI toolkit given that terminology has advanced since STEADI was first released and there is specific guidance on avoiding terms describing older adults that can otherize and evoke discrimination and negative stereotypes (e.g., elderly, seniors) [35]. Although we did not address terminology in our report, one option for CDC would be to rebrand the toolkit with more neutral and inclusive language such as “The STEADI Toolkit: Evidence-based approaches for preventing falls in older adults.” This approach offers CDC the opportunity to retain the STEADI brand while adding a tagline that succinctly describes the toolkit.